Anterior Cortical Impingement With 240 mm Cephalo-Medullary Nail (PFN and PFNA-2) in Intertrochanteric Femur Fracture Fixation in the Indian Population: A Problem Statement

Trochanteric fractures are common in the elderly population, and their incidence increases twice every decade after age 50. Intramural fixation has achieved good clinical efficacy in the treatment of unstable trochanteric fractures, but there have been complications reported in the literature in the Asian population. Most complications arise from a mismatch between the increase in the anterior femoral bow with advancing age and the proximal femoral nails (PFN) on the market, which still have straight designs on the sagittal plane. The non-anatomic shapes of the PFNs sometimes make the surgeries difficult or may lead to an inadvertent intraoperative fracture around the tip of the nail, particularly if they impinge on the anterior cortex of the femur. The entry point on the greater trochanter was divided into three equal parts, i.e., anterior 1/3rd, middle 1/3rd, and posterior 1/3rd on the lateral X-rays. Patients with posterior 1/3rd entry were excluded from the study as it is known that posterior positioning of nail entry can cause an increased incidence of anterior nail impingement. The AI was measured using the best available preoperative lateral roentgenogram of the femur using the incidence cortex (AI cortex) angle. This angle was measured using two tangential lines drawn parallel to the anterior cortex of the femur, proximal and distal to the most bowed point of the femur. We recommend that there is a need to introduce anterior curvature in the sagittal plane corresponding to the femoral bow in a 240 mm cephalomedullary nail to decrease complications. We also consider the use of either a short (i.e., 180 mm) or a long cephalomedullary nail in the Indian population, as the height of the population is shorter as compared to the western population, and the role of a 240 mm cephalomedullary nail is doubtful in the Indian population.